Hiccups

Background

• Usually initiated by gastric distention from food, carbonated beverage, or air
• Also known as Singultus

Clinical Features

• Hiccups

Differential Diagnosis

Hiccups

• Central nervous system disorders
  • Vascular
    • Ischemic/hemorrhagic stroke, AV malformations, temporal arteritis
  • Infections
    • Encephalitis, meningitis, brain abscess, neurosyphillis, subphrenic abscess
  • Structural
    • Head trauma, intracranial neoplasms, brainstem neoplasms, multiple sclerosis, syringomyelia, hydrocephalus
  • Vagus and phrenic nerve irritation
    • Goiter, pharyngitis, laryngitis, hair or foreign body irritation of tympanic membrane, neck cyst or other tumor
• Gastrointestinal disorders
  • Gastric distention, gastritis, peptic ulcer disease, pancreatitis, pancreatic cancer, gastric carcinoma, abdominal abscesses, gallbladder disease, inflammatory bowel disease, hepatitis, aerophagia, esophagael distention, esophagitis, bowel obstruction
• Thoracic disorders
  • Enlarged lymph nodes secondary to infection or neoplasm*, pneumonia, empyema, bronchitis, asthma, pleuritis, aortic aneurysm, mediastinitis, mediastinal tumors, chest trauma, pulmonary embolism
• Cardiovascular disorders
  • Myocardial infarction, pericarditis
• Toxic-metabolic
  • Alcohol
  • Diabetes mellitus
  • Herpes zoster
  • Hypocalcemia
  • Hypocapnia
  • Hyponatremia
  • Influenza
  • Malaria
  • Tuberculosis
  • Uremia
• Postoperative
  • General anesthesia
  • Intubation (stimulation of glottis)
  • Neck extension (stretching phrenic nerve roots)
  • Gastric distention
  • Traction on viscera
• Drugs
  • Alpha methyldopa
  • Short-acting barbituates
  • Chemotherapeutic agents (eg, carboplatin)
  • Dexamethasone
  • Diazepam
• Psychogenic
  • Anorexia nervosa
  • Conversion reaction
  • Excitement
  • Malingering
  • Schizophrenia
  • Stress

Diagnostic Evaluation

• Clinical diagnosis
• Consider auditory canal exam (foreign body against TM can trigger hiccups)
• Consider CXR

Management

• Physical Maneuvers (stimulating pharynx blocks the vagal portion of the reflex arc)
  • Remove foreign body from ear
  • Swallow teaspoon of sugar
  • Sip ice water
  • Drink water quickly
• Meds
  • Chlorpromazine 25–50mg IV; 25–50mg PO TID
  • Metoclopramide 10mg IV or IM; 10–20mg PO TID x 10d

Disposition

• Discharge for uncomplicated hiccups